MEDICARE ADVANTAGE SPECIAL NEEDS PLANS

 

Special Needs Plans (SNP)


How Medicare SNPs work


Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. Find out who can join a Medicare SNP.


Can I get my health care from any doctor, other health care provider, or hospital?


Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network, except:


  • Emergency or urgent care, like care you get for a sudden illness or injury that needs medical care right away
  • If you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis


Medicare SNPs typically have specialists in the diseases or conditions that affect their members.


Are prescription drugs covered? 


All SNPs must provide Medicare prescription drug coverage.


Do I need to choose a primary care doctor? 


In most cases, SNPs may require you to have a primary care doctor. Or, the plan may require you to have a care coordinator to help with your health care.


Do I have to get a referral to see a specialist?


In most cases, you have to get a referral to see a specialist in SNPs. Certain services don't require a referral, like these:


  • Yearly screening mammograms
  • An in-network pap test and pelvic exam (covered at least every other year)


What else do I need to know about this type of plan?


  • A plan must limit membership to these groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time.


  • Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders.


  • If you have Medicare and  Medicaid , your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid.


  

 

How Medicare Special Needs Plans (SNPs) work


Can I join a Medicare SNP?


You can join a Medicare SNP if you meet these requirements:




  • You meet the plan's eligibility requirements, like one of these:


  • Chronic Condition SNP (C-SNP): You have one or more of these severe or disabling chronic conditions:


  • Chronic alcohol and other dependence
  • Autoimmune disorders
  • Cancer (excluding pre-cancer conditions)
  • Cardiovascular disorders
  • Chronic heart failure
  • Dementia
  • Diabetes mellitus
  • End-stage liver disease
  • End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)
  • Severe hematologic disorders
  • HIV/AIDS
  • Chronic lung disorders
  • Chronic and disabling mental health conditions
  • Neurologic disorders
  • Stroke

  • Institutional SNP (I-SNP): You live in an institution (like a nursing home), or you require nursing care at home.


  • Dual Eligible SNP (D-SNP): You have both Medicare and Medicaid .


Each Medicare SNP limits its membership to people in one of these groups, or a subset of one of these groups.


For example, a Medicare SNP may be designed to serve only people diagnosed with congestive heart failure. The plan might include access to a network of providers who specialize in treating congestive heart failure. It would also feature clinical case management programs designed to serve the special needs of people with this condition. The plan's drug formulary would be designed to cover the drugs usually used to treat congestive heart failure. People who join this plan would get benefits specially tailored to their condition, and have all their care coordinated through the Medicare SNP.



What benefits and services are covered in Medicare SNPs?


Medicare SNPs cover the same Medicare services that all Medicare Advantage plans must cover. Medicare SNPs may also cover extra services tailored to the special groups they serve, like extra days in the hospital. Contact your plan to learn exactly what benefits and services the plan covers.


 
What do I pay in a Medicare SNP?


If you have Medicare and Medicaid, most of the costs of joining a Medicare SNP will be covered for you. Contact your Medicaid office for more information and to see if you qualify for Medicaid benefits.


If you don't have both Medicare and Medicaid (or get other help from your state paying your Medicare premiums), your exact costs will vary depending on the plan you choose. In general, you'll pay the basic costs of having a Medicare Advantage plan. 


 
What is a care coordinator in a Medicare SNP?


Some Medicare SNPs use a care coordinator to help you stay healthy and follow your doctor's orders. A care coordinator is someone who helps make sure people get the right care and information.


For example, a Medicare SNP for people with diabetes might use a care coordinator to help members do these things:


  • Monitor their blood sugar
  • Follow their diet
  • Get proper exercise
  • Schedule preventive services (like eye and foot exams)
  • Get the right prescriptions to prevent complications


A Medicare SNP for people with both Medicare and Medicaid might use a care coordinator to help members access community resources and coordinate their different Medicare and Medicaid services


 
When can I leave a Medicare SNP?


You can stay enrolled in a Medicare SNP only if you continue to meet the special conditions served by the plan.


Example


Mr. Johnson joined a Medicare SNP that only serves members with both Medicare and Medicaid. Mr. Johnson loses his Medicaid eligibility. Medicare requires Mr. Johnson's plan to disenroll him unless he becomes eligible for Medicaid again within the plan's grace period.


The grace period is at least one month long, but plans can choose to have a longer grace period. If you lose eligibility for the plan, you'll have a Special Enrollment Period to make another choice.


This Special Enrollment Period starts when your Medicare SNP notifies you that you're no longer eligible for the plan. It continues during the plan's grace period, and if you're disenrolled from the plan at the end of the grace period, it continues for 2 months after your coverage ends. It's very important to review your coverage options at this time to make sure you continue to have the Medicare health and prescription drug coverage you want.